Cost-effectiveness analysis of cervical cancer prevention based on a rapid human papillomavirus screening test in a high-risk region of China Carol E. Levin 1 , John Sellors 1 , Ju-Fang Shi 2 , Li Ma 3 , You-lin Qiao 2 , Jesse Ortendahl 4 , Meredith K.H. O’Shea 4 and Sue J. Goldie 4 1 PATH, Seattle, WA 2 Cancer Institute, Chinese Academy of Medical Sciences, Beijing, China 3 Dalian Medical University, Dalian, China 4 Center for Health Decision Science, Harvard School of Public Health, Boston, MA This study assessed the cost-effectiveness of a new, rapid human papillomavirus (HPV)-DNA screening test for cervical cancer prevention in the high-risk region of Shanxi, China. Using micro-costing methods, we estimated the resources needed to implement preventive strategies using cervical cytology or HPV-DNA testing, including the Hybrid Capture 2 (hc2) test (QIAGEN Corp., Gaithersburg, MD) and the rapid HPV-DNA careHPV TM test (QIAGEN). Data were used in a previously published model and empirically calibrated to country-specific epidemiological data. Strategies differed by initial test, targeted age, frequency of screening, number of clinic visits required (1, 2 or 3) and service delivery setting (national, county and township levels). Outcomes included lifetime risk of cancer, years of life saved (YLS), lifetime costs and incremental cost-effectiveness ratios (cost per YLS). For all screening frequencies, the most efficient strategy used 2-visit rapid HPV-DNA testing at the county level, including screening and diagnostics in the first visit, and treatment in the second visit. Screening at ages 35, 40 and 45 reduced cancer risk by 50% among women compliant with all 3 screening rounds, and was US$ 150 per YLS, compared with this same strategy applied twice per lifetime. This would be considered very cost-effective evaluated against China’s per- capita gross domestic product (US$ 1,702). By enhancing the linkage between screening and treatment through a reduced number of visits, rapid HPV-DNA testing 3 times per lifetime is more effective than traditional cytology, and is likely to be cost-effective in high-risk regions of China. Cervical cancer affects millions of individuals worldwide and is a leading cause of cancer death among women in develop- ing countries. 1 Although China registers a low average inci- dence of cervical cancer compared to many other regions of the world, the overall burden is large due to the size of the country’s population. Moreover, there is considerable hetero- geneity in terms of risk, with cervical cancer mortality rates in poor provinces such as Shanxi and Gansu exceeding 30 cases per 100,000. 2 Data available from one survey indicate that the prevalence of carcinogenic types of human papillo- mavirus (HPV) is 20.8% among 35- to 50-year-old women. 3 Since a national cervical cancer prevention program does not exist, most women have not been screened. 2 Cervical cancer has been reduced in countries able to implement organized secondary prevention programs that screen women with cytology at regular closely spaced inter- vals. 4 Unfortunately, the requirement for high-quality labora- tory and cytotechnologist support, coupled with the need for multiple visits, has proven difficult to implement in low- resource settings. Screening approaches that use HPV-DNA testing may prove more practical when incorporated into strategies less dependent on existing laboratory infrastructure and requiring fewer visits. 5,6 Most recently, a randomized trial in Osmanabad district in India demonstrated a single round of HPV-DNA testing among enrolled women between the ages of 30 and 59 years, was associated with a significant reduction in the number of advanced cancers and deaths Key words: cervical cancer, screening, cost-effectiveness, HPV, modeling Abbreviations: CICAMS: Chinese Academy of Medical Sciences; CIN: cervical intraepithelial neoplasia; DNA: deoxyribonucleic acid; GDP: gross domestic product; hc2: Hybrid Capture 2 test; HPV: human papillomavirus; LBC: liquid-based cytology; LEEP: loop electrosurgical excision procedure; YLS: years of life saved Additional Supporting Information may be found in the online version of this article. Presented in part at the International Papillomavirus Conference, Beijing, November 2007. Grant sponsor: Bill & Melinda Gates Foundation; Grant number: 30505 DOI: 10.1002/ijc.25150 History: Received 29 Aug 2009; Accepted 19 Nov 2009; Online 4 Jan 2010 Correspondence to: Carol E. Levin, PATH, 1455 NW Leary Way, Seattle, WA 98107, USA, Tel: þ206-285-2313, Fax: þ206-285-6619, E-mail: clevin@path.org Early Detection and Diagnosis Int. J. Cancer: 127, 1404–1411 (2010) V C 2010 UICC International Journal of Cancer IJC